ABSTRACT
Objective: The objective of this study is to analyze the risk perception of health professionals regarding the hospital waste management process before and during the Covid-19 pandemic, with the proposal of alternatives for improvements in the area of waste management in health services, whether public or private.
Theoretical Framework: This section addresses health service waste, focusing on the types of waste and the perception of risk surrounding them, providing a solid foundation for understanding the context of the investigation.
Method: The methodology adopted for this research includes the focus group method, endorsed by a literature review on the subject. The location defined for this research was a health unit that is a reference in cancer treatment, as it is a unit of the Unified Health System (SUS), which provides excellent service in health care, teaching, research, among other services.
Results and Discussion: By analyzing the risk perception of professionals, it was possible to identify the need for improvements in some waste management processes, including training, segregation, and internal communication. As a positive consequence, there is a reduction in costs associated with waste treatment, which is sometimes improperly sent to landfills, autoclaving, or incineration.
Research Implications: Improvement actions provide a reduction in environmental damage in the treatment processes of health service waste.
Originality/Value: It is believed that the knowledge obtained in this study reaches health service workers, generators of hazardous waste, as well as enables a deeper perspective on the development of training regarding the management of health service waste in institutions.
Keywords: Hospital Waste Management, Risk Perception, Healthcare Professionals, Covid-19 Pandemic.
RESUMO
Objetivo: O objetivo deste estudo é analisar a регсерсао de risco dos profissionais de saúde sobre o processo de manejo dos residuos hospitalares antes e durante a pandemia de Covid-19, com a proposta de alternativas de melhorias para a área de gestáo de resíduos nos servicos de saúde, sejam eles públicos ou privados.
Referencial Teórico: Neste tópico, abordam-se os resíduos dos servicos de saúde, dando enfoque aos tipos de resíduos e a percepção de risco sobre eles, fornecendo uma base sólida para a compreensão do contexto da investigação.
Método: A metodologia adotada para esta pesquisa compreende о método de grupo focal endossado pela revisão da literatura sobre o tema. O local definido para realizacáo desta pesquisa foi uma unidade de saúde referéncia em tratamento do cáncer, por ser uma Unidade do Sistema Único de Saúde (SUS), que presta servico de exceléncia em assisténcia a saúde, ensino, pesquisa entre outros servicos.
Resultados e Discussão: Ao analisar a percepção de risco dos profissionais foi possível identificar a necessidade de melhorias em alguns processos da gestão de resíduos, entre eles о treinamento, a segregação e a comunicação interna. Como consequência positiva, tem-se a redução dos gastos com o tratamento dos resíduos, por vezes, encaminhados indevidamente para aterros ou autoclavagem ou incineracáo.
Implicações da Pesquisa: As ações de melhorias proporcionam redução dos danos causados ао meio ambiente nos processos de tratamento dos resíduos de servicos de saúde.
Originalidade/Valor: Acredita-se que o conhecimento obtido neste estudo alcance os trabalhadores dos servicos de saúde, geradores de resíduos perigosos, assim como, possibilite um olhar mais profundo para o desenvolvimento de capacitações sobre o gerenciamento de resíduos de servicos de saúde nas instituições.
Palavras-chave: Gestão de Resíduos Hospitalares, Percepção de risco, Profissionais da Saúde, Pandemia da Covid-19.
RESUMEN
Objetivo: El objetivo de este estudio es analizar la percepción de riesgo de los profesionales de la salud frente al proceso de gestión de residuos hospitalarios antes y durante la pandemia de Covid-19, con la propuesta de alternativas de mejoras en el área de la gestión de residuos en los servicios de salud, ya sean públicos o privados.
Marco Teórico: Este tema aborda el desperdicio de los servicios de salud, enfocándose en los tipos de desperdicios y la percepción de riesgos que los rodean, proporcionando una base sólida para comprender el contexto de la investigación.
Método: La metodologia adoptada para esta investigación incluye el método de grupo focal avalado por la revisión de literatura sobre el tema. El lugar elegido para esta investigación fue una unidad de salud referencia en el tratamiento del cáncer, por ser una Unidad del Sistema Único de Salud (SUS), que presta servicios de excelencia en atención a la salud, enseñanza, investigación, entre otros servicios.
Resultados y Discusión: Al analizar la percepción de riesgo de los profesionales, fue posible identificar la necesidad de mejoras en algunos procesos de gestión de residuos, incluyendo capacitación, segregación y comunicación interna. Como consecuencia positiva se produce una reducción del gasto en tratamiento de residuos, que en ocasiones se envían indebidamente a vertederos, se esterilizan en autoclave o se incineran.
Implicaciones de la investigación: Las acciones de mejora proporcionan una reducción de los daños ocasionados al medio ambiente en los procesos de tratamiento de resíduos de servicios de salud.
Originalidad/Valor: Se cree que el conocimiento obtenido en este estudio abarca a los trabajadores de los servicios de salud, generadores de residuos peligrosos, además de permitir profundizar en el desarrollo de la capacitación sobre la gestión de los residuos de los servicios de salud en las instituciones.
Palabras clave: Gestión de Resíduos Hospitalarios, Percepción de Riesgos, Profesionales Sanitarios, Pandemia de Covid-19.
1 INTRODUCTION
Currently, urban solid waste (MSW) is one of the greatest environmental challenges for almost the entire world, since the lifestyle of individuals, excessive consumption, the production of waste in industries, and the disorganized urbanization process of some cities have been causing a continuous increase in its generation (Gouveia, 2012). According to Reis Neto (2019), in Brazil this situation is no different, it is among the 10 nations that generate the most MSW in the world, resulting from the growing development of cities, largely disorderly.
It is important to highlight that in 2020, the year the COVID-19 pandemic began, 82.5 million tons of MSW were generated in Brazil, according to the Brazilian Association of Public Cleaning and Special Waste Companies, during this period, there was a considerable increase in waste generation compared to previous years (ABRELPE, 2021).
Among the MSW generated, health service waste (HSW) stands out, that is, waste resulting from activities carried out by establishments that work in human and animal health (Brazil, 2018) . These are classified as infectious (Group A), chemical (Group B), radioactive (Group C), common (Group D) and sharp (Group E). They represent 2% of the total waste generated in the country (Rezende, 2015) .
In the context of the COVID-19 pandemic, due to the increase in the number of hospitalizations and outpatient care for the treatment of individuals infected with the CoV-2 as well as the vaccination of the entire population, there was a 14% increase in the collection of health service waste compared to the years 2019 and 2020 (ABRELPE, 2021), a much higher percentage when compared to previous years.
In parallel with the increase in the volume of waste generated, there was an increase in the risk of contamination of professionals, risks inherent to the waste management process, from its generation in health units to its final destination. According to Cafure and Patriarcha Graciolli (2015) , the incorrect disposal of RSS causes harm to public health, to the health of workers, as well as contaminates and degrades the environment.
This work aims to explore the perception of risks of health professionals regarding the management of HCW before and during the COVID-19 pandemic and to describe the proposed interventions to improve hospital waste management. The health unit chosen to carry out the study is reference in cancer treatment , an agency of the Ministry of Health belonging to the SUS that provides oncological care to the population, develops public policies, coordinates research and teaching in the area of oncology.
It is believed that the knowledge obtained in this study will reach health service workers, generators of hazardous waste, as well as enabling a deeper look at the development of training on the topic of RSS management in institutions and its risks in the management process, with healthcare professionals as the target audience.
2 THEORETICAL FRAMEWORK
2.1 HEALTHCARE WASTE
In Brazil, several laws provide support to minimize the impacts of RSS generation on human and animal health and the environment. The issue is to ensure that these are complied with both in the internal environment, in compliance with the Health Service Waste Management Plan (PGRSS) and in the external environment, in the inspection of companies that treat and dispose of waste (Cafure & Patriarcha-Graciolli, 2015) .
HCW belongs to a distinct subgroup of solid waste, which is waste resulting from activities carried out by health service waste generators (Brazil, 2018) . The dangerous nature of HCW is associated not only with infections transmitted through secretions and blood, but also with injuries caused by incorrectly discarded sharp or piercing objects, as well as diseases related to soil contamination caused by inadequate final disposal of HCW (Cozendey-Silva et al. 2018). 2016).
Infectious waste, classified as group "A", is waste that presents a higher risk of infection. With potential risk to public health and the environment due to the presence of biological agents, these include: blood, secretions, laboratory animal carcasses, transfusion bags, dressings with a large volume of secretion, and anatomical parts that have no scientific or legal value (RDC No. 222) (Brazil, 2018). Also in this same ANVISA Resolution, this group of waste is subdivided into Al, A2, A3, A4 and AS, and differs according to the degree of danger they represent to the health of workers and the environment, thus defining the form of treatment for them.
The treatment indicated for waste contaminated by the Sars-Cov-2 virus is the same as that carried out for infectious waste from subgroup Al, as recommended by Technical Note 04/2020 from ANVISA, supported by RDC No. 222 (Brazil, 2018), an autoclaving or incineration process or another form of inactivation of the microbial load.
Chemical waste classified as group "В" has characteristics of corrosivity, reactivity, flammability, toxicity, cytogenicity and explosiveness. In the study on the perception of nursing professionals, Costa et al . (2012) revealed that the management of chemical waste represents an additional concern for the nursing team due to the lack of knowledge of the dangers to which they are exposed and the lack of knowledge about appropriate management. They also report that they receive little information about the risks and impacts and harm to health and preventive measures.
Radioactive waste, classified as group "С", results from human activities that contain radionuclides in quantities exceeding the elimination limits specified in the National Nuclear Energy Commission (CNEN) standard in NE-6.02. Although radioactive waste, group C, is generated in the hospital, it will not be treated in this study, due to its own specific legislation guided and supervised by CNEN.
Common waste, classified as group "D", is that which can be compared to household waste. This waste is similar to MSW (RDC n° 222) (Brazil, 2018). It is sent to Sanitary Landfills and does not require treatment before final disposal.
Sharp waste, classified as "Group Е", is sharp or scarifying material. The treatment of this waste, when contaminated by biological, chemical or radioactive substances, must be managed according to each associated risk class (RDC No. 222) (Brazil, 2018).
The action of managing RSS internally and externally to the establishment, from its generation to its final disposal, is defined as management. It covers the stages of segregation, packaging, identification, internal transport, temporary storage, internal treatment, when necessary, external storage, external collection and transportation, external treatment, when necessary, and final disposal (RDC No. 222) (Brazil, 2018).
2.2 RISK PERCEPTION REGARDING HEALTHCARE WASTE
For neuroscience, "perception refers to the ability, in human beings, to associate sensory information with memory and cognition, in order to form a representation and in turn, a concept about 'reality' and about ourselves, guiding our behavior" (Lent, 2010).
Regarding risk, Navarro's interpretation (2009, p. 47) suggests that,
"Risk is a possibility of harm that is related to an eventuality: it means a threat to institutions, companies, people and their values. It is up to each person to react to these factors to protect their own safety and that of the people and institutions for which they are responsible. Therefore, risk awareness is linked to the internal perception of individuals, their fragility to these factors, as well as their ability to successfully react. Risk perception, on the other hand, is the awareness that something bad or harmful could happen."
When it comes to managing waste from human or animal health care services, the risks are obvious; their management involves risks to both the health of workers and the environment. The Brazilian Association of Technical Standards (ABNT), through ISO 31000, provides guidance on Risk Management, its Principles and Guidelines, stating that all activities of an organization involve risks and that organizations need to manage, identify and analyze these risks ( ABNT, 2009) .
According to Gomes et al . (2019) , these risks are not restricted to workers who provide direct patient care; all workers are exposed. They believe that there are still no epidemiological studies in Brazil regarding this exposure to infection risks for hospital cleaning professionals, warning that this is a public health problem.
In the study by Pereira et al . (2010), HCW poses different risks to employees, patients and the community in general. In relation to employees, these risks are related to occupational accidents. Paiz et al . (2014) raised issues related to the inadequate storage of HCW in their study, highlighting that the hospital environment is an opportune place for the emergence of several organisms and vectors, accumulating several pathologies that can be transmitted by rodents and insects, among others, confirming the need for differentiated management of this waste.
Some studies have published detailed guidelines for the management of HCWs with suspected or confirmed contamination by Sars-Cov-2, to avoid greater impacts on patient care. Going beyond ANVISA guidelines, reconciling company standards, state and municipal legislation, as is the case of Ventura et al. (2021) , who described a compilation of the main guidelines adopted in the city of Araraquara, Sáo Paulo.
Peng et al. (2020) emphasize the importance of valuing any aspect of prevention and control of Sars-Cov-2, due to its high degree of infectiousness. Ensure that the actions proposed for the management of this waste are strictly followed to reduce the risk of a pandemic in the hospital environment.
As in Brazil, China, Spain, Thailand and the United Kingdom reported in their studies the increase in the generation of health service waste in 2020 (Alomari et al .,2021), attributing this fact to the high demand for medical care, hospitalizations and outpatient consultations, due to the rapid spread of the disease.
The environmental impact of the generation of HCW during this period was easy to perceive. The large amount of disposable materials used, especially personal protective equipment, which needed to be changed after each contact with patients and became mandatory for all professionals working in hospital care. In this scenario, it is possible to understand that there was an increase in demand for companies that worked with equipment for thermal treatment of waste, such as autoclaves and waste incinerators.
3 METHODOLOGY
The purpose of this study is to develop an applied research with a qualitative approach, followed by the hypothetical-deductive method. The focus group was used as the research strategy. It is important to emphasize that this research was authorized by the Ethics and Research Committee of the Institutions.
The focus group (FG) participants are experts in the area of waste management and healthcare professionals, preferably those from the nursing team, as they represent the largest contingent of workers in the healthcare field, working in direct patient care, as well as being directly involved in the generation of waste.
A semi-structured script was used to collect information through the focus group. For Marconi and Lakatos (2002, p. 92), "it is a procedure used in social research, to collect data or to help in the diagnosis or treatment of a social problem". The criteria used to prepare the focus group script were based on a literature review and the recommendations of RDC n 222/2018 of ANVISA.
The FG was carried out in a Health Unit that is a reference in cancer treatment . The choice was based on the following criteria: Unit that offers various types of care services to cancer patients; greater representation in terms of the volume of waste generated; greater number of beds and outpatient consultations, among the 4 care units belonging to the complex.
The criteria for defining the focus group participants used the intentional sampling strategy, according to Gray (2012), which is the selection of a group, using a population, with characteristics, that can be divided into subgroups. The sectors defined for choosing the study participants are those in which the waste generated presents a greater risk of contamination as shown in Table 1. The waste managers defined for the study are those who work in the Unit.
The second criterion for defining participants took into account the location where healthcare professionals work. In this sense, the waste generated in these sectors presents characteristics of greater risk of contamination and toxicity, and in these locations, we found a greater representation of the waste generated, when compared to other hospital admission areas.
The choice of waste management representatives is justified because they are professionals working in waste management at the Unit, and the other waste managers are located in nearby units, geographically, facilitating their travel to the meeting with the focus group.
To test the methodology and the script prepared for the interview with the focus group, a pre-test was carried out to be used in the empirical research of this work, with the presence of 5 participants, 2 health professionals, 1 waste manager and 2 researchers.
In general, the proposed script seemed to encourage dialogue between participants with a view to answering the questions in this research. However, it seemed relevant to include the concept of risk in the script, in the first guiding question, so that it could be more clearly differentiated from the second question. This is because similarity was observed in the participants' answers to both questions, as if the difference between them was not clear. The meeting lasted approximately 1 hour and 10 minutes.
According to the article by Gui (2003):
"In a focus group, the aim is not to achieve consensus, but rather to achieve diversity of ideas. The interaction of participants is highlighted within the group, based on the script presented by the researcher, who assumes the role of moderator. The main interest is to recreate, in this way, a context or social environment where the individual can interact with others, defending, reviewing, ratifying their own opinions or influencing the opinions of others. This approach also allows the researcher to deepen his understanding of the responses obtained."
The FG followed the same planning as in the pre-test, the participants were selected according to their profile, as shown in Table 1, with eight (8) civil servants being invited to participate in the study, but only seven (7) participated voluntarily. It should be noted that the absence of this participant did not influence the development of the FG. The signing of the Informed Consent Form (ICF) and other formalities were requested, with a duration of 1 hour and 40 minutes.
The previously prepared script was adjusted to meet the needs of this second FG, including the objectives of the interview and the questions selected for the study. The main researcher of the Unit contacted the group participants in advance, and they were officially invited to the focus group by sending an e-mail to their personal address and messages via cell phone, with the invitation letter containing the location, date and time set for the FG.
After the FG was completed, the recorded audio was transcribed, together with the notes made by the researcher and assistants. After this stage was completed, the content analysis was concluded.
The script prepared for the focus group was predefined and served as a basis for structuring the content analysis. In this stage of the research, in addition to the analysis of the transcription of the recorded audios, the recording made by the assistant was used.
The data were analyzed using the content analysis method proposed by Laurence Bardin. This technique aims to collect as much information as possible and organize it in a way that answers the research problem can be obtained. To this end, all themes that have similar meanings were grouped together, thus forming thematic categories and subcategories (Bardin, 2016) . In Bardin's analysis method, the organization is divided into three chronological stages: Ist Pre-analysis, 2nd Exploration of the Material and 3rd Treatment, inference and interpretation.
In the material exploration phase, the raw data collected were coded and categorized. This coding aims to classify the elements, transforming them into units, which later form the categories and the corpus of analysis. (Lima, 2018) . Below are the stages of the organization phase defined by Bardin.
4 ANALYSIS AND DISCUSSION
To maintain the reliability of the information, the names of the focus group participants were replaced by Pi, Р2, РЗ, P4 (health professionals) and G5, G6 and G7 (waste area managers). The statements were transcribed literally.
From the analysis of the GF content with the support of the script with semi-structured questions, 3 categories and 6 subcategories were identified , as shown in table 3.
4.1 RISK PERCEPTION BEFORE AND DURING THE COVID-19 PANDEMIC
In the context of risk perception, it is observed in the speech of subjects P1 and G7 as something already incorporated into their daily work routine.
"You work there all the time, you're already very used to doing everything, so when COVID came, I think we started to pay a little more attention. And we thought, no, wait a minute, let's review all the precautions we take. Do you understand? And we started to pay more attention, more care in relation to this [...] to avoid getting contaminated, not contaminating the environment, do you understand?" (P1).
"So, before they collected normally, because I think that when it becomes part of your daily routine, a habit, you start doing it as part of your routine, and you don't think about the risks, right? And when COVID came, people stopped to think about what they were doing in a habitual, routine way. So you saw when it was time to collect, they were afraid of - Oh, the red bag" (G7).
The COVID-19 pandemic has had an impact on professionals, such as rethinking and denaturalizing risks, paying more attention, reviewing their behavior, being more concerned about something new and unknown, being afraid, and needing to identify risks that may be present in their routine activities. Subject G7 complements his statement by drawing attention to the naturalization of risk: " So, what does a person do оп a normal day, work normally, as if there were no risk at all, but deep down everyone knows that this generates a risk" (G7).
It can be seen through these statements that the risks were being treated in a trivial way, naturalized in their day-to-day activities, and with the pandemic this perception was brought to the surface and they began to protect themselves more, to worry about the risks to which they were exposed.
The risk perception of all professionals was evident, highlighting that at that time, in which the number of cases of contamination and deaths from COVID-19 reduced drastically, professionals began to have the same risk perception as before the pandemic with the management of RSS.
4.1.1 Use and handling of PPE by healthcare professionals
The statements of subject P2 reveal that, in fact, what worried him most, when it came to hospital waste management, was the use and handling of Personal Protective Equipment (PPE), especially when it came to segregating and disposing of it.
"Now after the pandemic, as P1 said, that concern we had, for example, when it came to disposing of PPE, is most often the moment when the professional becomes infected. Therefore, the rigor and fear of professionals regarding illness from COVID-19 increased a lot" (P2).
In the following statement, it is clear that even when dealing with health professionals, before the COVID-19 pandemic, there was some carelessness with the use of PPE as protection against the risks existing in their daily activities,
"Because now there is greater use, routinely, the use of PPE ends up falling into disuse, you end up abusing it and not using it. Maybe with the pandemic people were more worried about COVID than BK, and so, anyway, it's not that we don't have to worry about COVID" (P4).
The COVID-19 pandemic has had a positive impact on the perception of the need for healthcare professionals to use PPE, and to a certain extent, it has been perceived that the risks of contamination from other sources of contagion, already existing in their routine activities, have been neglected. The correct disposal of personal protective equipment was mentioned as a high risk of contamination by COVID-19.
4.1.2 Perception of environmental risks by healthcare professionals
It is worth noting that during the focus group, only one of the respondents from the group of health professionals demonstrated awareness of the existence of risks to the environment related to HCW. Subject P2 demonstrated that he was aware of the existence of a HCW treatment process even before the COVID-19 pandemic.
"I know that chemotherapy waste goes through an incineration process, so, in the same way as it was done before the pandemic, it continues due to the level of danger" (P2).
No knowledge was demonstrated about the impacts of this waste treatment on the environment. The existence of an autoclave in the Institution was mentioned only by subject P4, demonstrating concern about the internal treatment of RSS.
4.2 FAILURES IN THE WASTE MANAGEMENT PROCESS
4.2.1 Inadequate segregation
segregation compromises all other stages of management, for Garcia and Zanetti-Ramos (2004), it is at this stage that the risks existing in that residue are defined.
In the following context, regarding the segregation of sharp waste in the wards, it is clear that health professionals are aware of the risks that these represent, especially for those who are not trained to deal with it. In the statements of subjects P3 and P4, companions and visitors of hospitalized patients were highlighted.
"It's another problem we're going to have, when we have a companion for the patient again, they put everything in the descarpack ·, you know? They mix things up" (РЗ).
"It's hazardous waste, right? That's the truth, it's a complicated waste for those who don't have training. [...] We saw a lot of incorrect disposal points, we saw a lot of common waste discarded as biological waste, a lot of biological waste that is discarded as sharps" (P4).
The participants were asked about the period in which they noticed episodes of failure in waste segregation. It was clear, due to the agility in the response of most participants, including those speaking at the same time, that failures in segregation were common, even before the pandemic:
In their study, Aduan et al . (2014) conclude, among other issues, that correct segregation at the generating source reduces the risk conditions to worker health and the environment.
4.2.2 Identification and packaging
One of the most visible practical changes that occurred in waste management during the pandemic period was the packaging, the implementation of red bags in the trash cans of rooms, wards or any area intended for patients infected with the Sars-CoV-2 virus. As indicated by the statement of subject P4: "There was a change in the packaging, which was the issue of the red bag. In the wards, there were trash cans that were placed outside, because when the person left the isolation area and such, they would already take off the PPE and put it there in the trash can outside" (P4).
It is clear that this guidance was successful, drawing attention to the risks of HCW contaminated by the COVID-19 virus. For Alves and Nunes (2018), proper packaging reduces risks to the health of workers, facilitates handling, safer storage, and contributes to the management stages within and outside the health facility.
The identification and packaging of waste are close and important steps in the management of RSS. According to Yallew et al. (2017), properly packaging waste contributes to reducing hospital infection rates.
In the following statement, it can be seen that subject G7 demonstrates concern about the risks to which external waste collectors are exposed, with other hazardous waste generated in the hospital and stored in a milky white bag.
"As the collectors on the truck were also extremely afraid of COVID, for example, there was Hepatitis, there were other things, but people only looked at the red bag. So, we made sure to also identify the containers that came from the COVID area [...] so you saw a concern that if it weren't for the red bag, they would be collecting there normally" (G7).
The authors Dancewicz et al. (2005) and Arafa and Eshak (2020) address in their studies the risks to which professionals who work in the collection and external transportation of RSS are exposed. This exposure is mainly due to contamination by Hepatitis and HIV, as highlighted by subject P4: "Maybe with the pandemic, people were more worried about COVID than BK (tuberculosis), and so, in short, it's not that they don't have to worry about COVID" (РА).
4.3 ACCESS TO (IN)FORMATION
4.3.1 Communication
This subcategory investigated the level of knowledge that professionals would have about the Institution's PGRSS. For Ferrareze ег al. (2005), the PGRSS provides several benefits for the institution, such as: reducing environmental risks, the number of work accidents, costs with unnecessary waste treatment, increased recycling and reduced volume of waste generated.
The question in question was "Are you familiar with the PGRSS (Health Service Waste Management Plan), a management tool used in the waste area? If so, do you think this document could include more information about the risks inherent in the waste management process?" Unfortunately, none of the health professionals present were aware of the existence of this Plan. In this context, it is important to emphasize that the way the documents are made available at the Institution is through the Intranet, a portal that unifies the organization's information and data system. From what we can see, this form of disseminating the PGRSS is not enough to reach the professionals who work on the front lines.
4.3.2 Training
In the training subcategory, a question was raised about the training implemented at the Institution on waste management. The following question was used in the script: "Are the information and training available on waste considered important and sufficient to prevent accidents with waste, both for the worker and for the environment?"
Several articles conclude that training is essential for managing HCW. With the pandemic, distance learning has become a great ally. For Oliveira ef al . (2020), in addition to being essential, it was a means of communication that enabled access to education at a time when in-person education became unfeasible due to the risk of contagion. At Unidade, this tool has been in existence for a few years. The Waste Management course, in the distance learning format, was developed in 2013. As reported by subjects G7 and P4.
"It was designed to help train healthcare professionals and to meet the needs of the Waste Commission's reduced team" (G7).
"[...] I think that with the advance of the pandemic, remote education is here to stay, right? It was something that people weren't used to before, it wasn't an attractive modality, I think that today that has changed completely [...]" (P4).
"[...] I don't know how this issue of continuing education is going, maybe it could be a path [...] like that, really EAD for people to seek voluntarily, [...], it's very difficult" (P4).
When asked about the importance of training on the topic of health service waste, there was unanimity in saying that yes, it is extremely important. However, when asked about adherence to existing training at the Institution, health professionals demonstrated ignorance of it, justifying it with the lack of time. and staff for low adherence. According to subject G7:
"So, we have a participation issue here, because we have a distance learning course on waste management, but we have difficulty with adherence, because there is not enough HR, and everyone is worried about patient care. So where can we find time for these people to get out of their world and participate in training, even if it is distance learning [...] now let's talk about waste - Oh, right now, that's not possible, right? Because there's a patient here that I have to see."
According to Navarro (2009), when haste is the top priority, several procedures are left aside, making room for shortcuts that favor the occurrence of accidents. It is important that all healthcare professionals value the issue of waste. The risks of accidents involving waste exist and training on the subject becomes a great ally.
It is clear that the dissemination of the waste management course promoted by the institution does not reach all healthcare professionals; it is important to review the way courses are disseminated internally.
When asked about what changes would be necessary to improve the cleaning team's service, the need for training on the use of PPE was cited by all respondents, as pointed out by subjects P1 and G5.
"I think people could have better training in relation to the use of PPE, for their protection, you know?" (P1).
"[...] they are very poorly trained, so I don't know if it's because of the company's change." (G5).
According to Gomes et al. (2019), it is concluded that continuing education focused on the use of PPE is essential to reduce workplace accidents. When it is realized that training can prevent risks to workers' health, it is necessary to more effectively demand that contractors of hospital cleaning service providers take this action, together with cleaning employees. At this point, a brief analysis of the outsourcing of this service is in order. Despite bringing many benefits, such as: faster hiring and faster replacement of workers in absences due to absence or vacation, in the high turnover of workers, replacements are usually made by untrained professionals with no connection to the institution. Thus, exposure to the risks inherent to the activity increases.
5 CONCLUSION
It is worth mentioning that several improvement actions were implemented in the Institution after the publication of Resolutions 306/2004, updated by Resolution No. 222/2018, between 2004 and 2020, the period preceding the COVID-19 pandemic. This fact is considered to be of great relevance due to the structural conditions of the existing Waste Commission, especially with regard to the lack of human resources allocated exclusively to this activity.
Despite the various actions implemented to improve waste management, The perception of risk among healthcare professionals regarding the waste management process still requires greater caution.
It was clear from the statements of health professionals that risks were being dealt with routinely, in their day-to-day activities, and with the pandemic this perception was heightened, they began to protect themselves more and worry about the risks to which they were exposed.
Comparing waste management carried out before and during the COVID-19 pandemic, changes in the color of infectious waste packaging bags, the mapping of infectious waste bins to serve the wards of patients infected with the virus and the increase in the generation of infectious waste were some of the most highlighted changes in this study.
Awareness among healthcare professionals regarding their responsibility for managing HCW should be seen from generation to final destination. It was noted that this responsibility for management was attributed exclusively to cleaning assistants.
For waste managers, it was not difficult to see that the perception of risk is present in their daily work, but issues such as the lack of human resources dedicated exclusively to working on waste management, planning and efficiently executing daily activities, as well as seeking solutions for new demands, are exhausting and tiring, making it difficult to operate efficiently on so many work fronts. It is therefore clear that this is a problem that needs to be valued by the institution's senior management. The implementation of an environmental management system, as described in ISO 14001, is urgent and requires dedicated professionals to implement it.
In this study, it was clear that the appreciation of Personal Protective Equipment (PPE) during the COVID-19 pandemic by all participants was the risk perception initiative that stood out the most. However, this new reality revealed an impact on the environment with the large volume of waste generated by this immense demand for disposable items.
Waste managers reported that the PGRSS does not include sufficient information on the risks generated in the waste management process. It is worth noting that the inclusion of this information does not guarantee that failures will not occur, but it does seek to provide guidance on reducing the risks arising from waste management.
Health professionals demonstrated knowledge about some stages of waste management, but little awareness of the risks they pose to the environment and public health.
In the context of this study, recommendations for actions to improve waste management were revealed. These recommendations are related to the categories and subcategories identified in the focus group:
* Train all members of the waste production chain, to this end, review the planning of the distance learning course and improve internal promotion of the course;
* Develop promotional materials with information for companions and visitors about the segregation of waste generated;
* Analyze the contract with the outsourced hospital cleaning company, especially with regard to the use of PPE.
* Detail the Waste Management Plan in standard operating procedures (SOP) and publish it;
* Include in the PGRSS guidelines regarding the risks of each stage of waste management.
Considering the complexity of waste management and the difficulties in carrying out all the activities provided for in the PGRSS, it is necessary to demonstrate to the institutions' senior management the need for human resources allocated exclusively to this activity, both for inclusion in the next competitions and in the current internal reshuffles. As an immediate and easy-to-implement action, create work groups with professionals interested in the topic, using the Cleaner Production procedure that uses the Ecotime concept .
In short, all these actions need to be discussed involving the members of the waste chain: managers, assistance, teaching, research, outsourced companies and even other services that are part of the Institution and that are also waste generators, for the implementation of these measures aimed at achieving the objectives outlined in this study and that protect the health of workers, the community and the environment.
Finally, it is concluded that, during this pandemic period, there was a broad perception of the importance of the correct use of PPE in preventing contamination risks. The need for training for the correct management of waste in all its stages and for the handling of PPE was perceived in this study as a relevant factor for the adequate management of waste, minimizing risks to worker health and damage to the environment both before and during the COVID-19 Pandemic.
As a recommendation for future work, it is suggested that a similar study be carried out with professionals who work in hospital cleaning to analyze their risk perception.
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4 Descarpack is one of the brands of boxes, in yellow, standardized and approved for the disposal of contaminated sharp waste.
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Abstract
Objective: The objective of this study is to analyze the risk perception of health professionals regarding the hospital waste management process before and during the Covid-19 pandemic, with the proposal of alternatives for improvements in the area of waste management in health services, whether public or private. Theoretical Framework: This section addresses health service waste, focusing on the types of waste and the perception of risk surrounding them, providing a solid foundation for understanding the context of the investigation. Method: The methodology adopted for this research includes the focus group method, endorsed by a literature review on the subject. The location defined for this research was a health unit that is a reference in cancer treatment, as it is a unit of the Unified Health System (SUS), which provides excellent service in health care, teaching, research, among other services. Results and Discussion: By analyzing the risk perception of professionals, it was possible to identify the need for improvements in some waste management processes, including training, segregation, and internal communication. As a positive consequence, there is a reduction in costs associated with waste treatment, which is sometimes improperly sent to landfills, autoclaving, or incineration. Research Implications: Improvement actions provide a reduction in environmental damage in the treatment processes of health service waste. Originality/Value: It is believed that the knowledge obtained in this study reaches health service workers, generators of hazardous waste, as well as enables a deeper perspective on the development of training regarding the management of health service waste in institutions.